The Emergence of Dry Needling in Stroke Rehabilitation

Abstract

The management of stroke, acute revascularization and rehabilitation techniques have taken a giant leap in the current decade. The presence of neurological deficits, spasticity and pain are the common limiting factors in post-stroke patients. The various rehabilitation measures in stroke are focused on improving the trio. Spasticity, in a post-stroke patient, is disabling and can be managed using oral pharmacological agents, botulinum toxin, intrathecal baclofen. The use of needle therapy, dry needling, which was commonly used in the management of myofascial pain syndromes has emerged useful in the management of spasticity. Further recent evidence has shown it to be useful in the other dimensions of stroke rehabilitation. Dry Needling is a skilled intervention, that is performed by trained personnel using a filiform needle. It can be performed superficially or deep. The speculative mechanisms by which dry needling reduces spasticity include inducing stretch in the muscle and afferent modulation of the sensory information from the muscle. It improves blood flow and oxygenation, reduces pain through central and peripheral mechanisms. (1) The use of dry needling in neurology has evolved from its use in the management of myofascial pain to spasticity in spastic tetra paresis and stroke rehabilitation. In post-stroke patients, dry needling has been used in the management of post-stroke spasticity, balance, post-stroke pain. In the management of spasticity, dry needling using ‘pistoning technique’ in the lower limbs (gastrocnemius, tibialis posterior) and upper limbs (shoulder, elbow and wrist) revealed improved scores in modified modified Ashworth scale (MMAS) that translated to improved gait and range of upper limb motion respectively. The dry needling was performed for 1 minute in each muscle studied. However, the number of sessions varied from a single session to 8-week therapy between studies. In the management of balance, the dry needling of the involved tibialis posterior muscle improved the balance as measured by single-leg stance, balance component of Fugl-Meyer scale and dynamic posturography. The improvement in the above measures is also shown to improve the functional outcome of post-stroke patients in Barthel index, 10-metre walk test, timed up and go test. The dry needling is shown to reduce pain including post-stroke shoulder pain by reducing the pain threshold. The above effects of dry needling were also evident in ultrasound assessment of the intervened gastrocnemius muscle that showed improved muscle length, reduced mean muscle thickness and angle of pennation. (1-3) The dry needling has also been studied in post-stroke rehabilitation as a component of the multimodal approach. The use of dry needling in conjunction with electrical stimulation of the muscle is shown to produce persistent improvement in the tone of the muscle. The adverse events noted following the use of dry needling include post interventional muscle soreness, bleeding, bruise and pain during the intervention. Major side effects such as loss of consciousness are rare and hence dry needling serves as a safe therapeutic option in the rehabilitation of post-stroke patients. (1-3) Hence dry needling is a safe, cost-effective technique that can be used in the management of post-stroke spasticity, balance, pain that translates to improved functional outcomes. However, further evidence is required to establish the efficacy of this promising technique in the management of post-stroke rehabilitation.